A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?
Observe for signs of infection
Examine the skin for generalized urticaria
Review laboratory test results for low hemoglobin
Monitor the mouth for signs of xerostomia
The Correct Answer is A
Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.
- Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
- Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
- Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Dyspnea:
Dyspnea (shortness of breath) is a common symptom in emphysema due to the destruction of alveolar walls and the resulting reduction in surface area for gas exchange. As the disease progresses, the patient experiences increasing difficulty in breathing, especially during exertion or when the disease becomes more severe.
B. Barrel chest:
A barrel chest is often seen in emphysema, as it results from hyperinflation of the lungs. The increased air trapping due to damaged alveoli causes the chest to expand and become rounded, leading to the characteristic "barrel chest" appearance. This happens because the lungs are constantly overinflated, and the chest wall becomes rigid and rounded as a result.
D. Clubbing of the fingers:
Clubbing of the fingers can occur in chronic respiratory conditions like emphysema due to prolonged hypoxia (low oxygen levels in the blood). This is a compensatory mechanism that involves changes in the nails and fingers. The tips of the fingers become rounded and bulbous over time, and this is commonly associated with long-standing pulmonary diseases.
Correct Answer is A
Explanation
Using a bronchodilator 1 hour before eating can help reduce dyspnea and improve appetite for a client who has COPD. It can also facilitate oxygen delivery to the tissues and prevent hypoxia.
b) Eating 3 large meals each day is not recommended for a client who has COPD, as it can cause abdominal distension and increase pressure on the diaphragm, leading to dyspnea and fatigue. A better option is to eat 5 to 6 small meals throughout the day.
c) Limiting water intake with meals is not advisable for a client who has COPD, as it can cause dehydration and increase the viscosity of secretions, making them harder to expectorate. A better option is to drink at least 2 L of fluids per day, preferably between meals.
d) Reducing protein intake is not beneficial for a client who has COPD, as protein is essential for maintaining muscle mass and strength, especially of the respiratory muscles. A better option is to increase protein intake to at least 1.2 g/kg of body weight per day.
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